Normothermic Machine Perfusion and Normothermic Regional Perfusion of DCD Kidneys Before Transplantation: A Systematic Review.

BACKGROUND: To overcome organ shortages, donation after circulatory death (DCD) kidneys are being increasingly used for transplantation. Prior research suggests that DCD kidneys have inferior outcomes compared with kidneys donated after brain death. Normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP) may enhance the preservation of DCD kidneys and improve transplant outcomes. This study aimed to review the evidence surrounding NMP and NRP in DCD kidney transplantation. METHODS: Two independent reviewers conducted searches for all publications reporting outcomes for NMP and NRP-controlled DCD kidneys, focusing on delayed graft function, primary nonfunction, graft function, graft survival, and graft utilization. Weighted means were calculated for all relevant outcomes and controls. Formal meta-analyses could not be conducted because of significant heterogeneity. RESULTS: Twenty studies were included for review (6 NMP studies and 14 NRP studies). Delayed graft function rates seemed to be lower for NRP kidneys (24.6%) compared with NMP kidneys (54.3%). Both modalities yielded similar outcomes with respect to primary nonfunction (NMP 3.3% and NRP 5.6%), graft function (12-mo creatinine 149.3 µmol/L for NMP and 129.9 µmol/L for NRP), and graft utilization (NMP 83.3% and NRP 89%). Although no direct comparisons exist, our evidence suggests that both modalities have good short- and medium-term graft outcomes and high graft survival rates. CONCLUSIONS: Current literature demonstrates that both NMP and NRP are feasible strategies that may increase donor organ utilization while maintaining acceptable transplant outcomes and likely improved outcomes compared with cold-stored DCD kidneys. Further research is needed to directly compare NRP and NMP outcomes.

Kidney Transplantation Outcomes From Uncontrolled Donation After Circulatory Death: A Systematic Review and Meta-analysis.

BACKGROUND: Uncontrolled donation after circulatory death (uDCD) is a potential additional source of donor kidneys. This study reviewed uDCD kidney transplant outcomes to determine if these are comparable to controlled donation after circulatory death (cDCD). METHODS: MEDLINE, Cochrane, and Embase databases were searched. Data on demographic information and transplant outcomes were extracted from included studies. Meta-analyses were performed, and risk ratios (RR) were estimated to compare transplant outcomes from uDCD to cDCD. RESULTS: Nine cohort studies were included, from 2178 uDCD kidney transplants. There was a moderate degree of bias, as 4 studies did not account for potential confounding factors. The median incidence of primary nonfunction in uDCD was 12.3% versus 5.7% for cDCD (RR, 1.85; 95% confidence intervals, 1.06-3.23; P = 0.03, I 2 = 75). The median rate of delayed graft function was 65.1% for uDCD and 52.0% for cDCD. The median 1-y graft survival for uDCD was 82.7% compared with 87.5% for cDCD (RR, 1.43; 95% confidence intervals, 1.02-2.01; P = 0.04; I 2 = 71%). The median 5-y graft survival for uDCD and cDCD was 70% each. Notably, the use of normothermic regional perfusion improved primary nonfunction rates in uDCD grafts. CONCLUSIONS: Although uDCD outcomes may be inferior in the short-term, the long-term outcomes are comparable to cDCD.

Outcomes of endovascular, open surgical and autotransplantation techniques for renal artery aneurysm repair: a systematic review and meta-analysis.

BACKGROUND: Renal artery aneurysms (RAA) can be repaired with endovascular exclusion (EVR), open repair (OR), or ex-vivo repair with renal autotransplantation (ERAT). This systematic review compares repair indications, aneurysm characteristics, and complications following these interventions. METHODS: A systematic review of databases including MEDLINE, PUBMED, and EMBASE by two independent reviewers for studies from January 2000-November 2022. All studies evaluating repair indications, RAA morphology, morbidity and mortality following EVR, OR, and ERAT were included. RESULTS: A total of 38 studies were included with 1540 EVR, 2377 OR and 109 ERAT subjects. Increasing aneurysm size, or diameters >20 mm, were the most common repair indications across EVR and OR (n = 537; 48%), and ERAT (n = 23; 52%). All ERAT repairs were at or distal to renal artery bifurcations (n = 46). Meta-analyses demonstrated significantly shorter length of stay (LOS) with EVR compared to OR (mean difference -4.06, 95% confidence interval (CI) -5.69 to -2.43, P < 0.001). No significant differences were found in mean aneurysm diameter (P = 0.23), total complications (P = 0.17), and mortality (P = 0.85). Major complications (Clavien-Dindo ≥III) across studies most commonly included acute renal failure (EVR 4.9% vs. OR 7.0%). Nephrectomy was the most common major complication in ERAT (5.5%). CONCLUSIONS: Outcomes following EVR and OR of RAAs are comparable. EVR offers a shorter LOS, with no difference in morbidity or mortality. ERAT is currently only utilized for distal RAAs, however carries higher risk of infarction and nephrectomy necessitating specialized expertise or algorithms to assist appropriate selection of repair methods.

Phaeohyphomycosis in Kidney Transplant Recipients: Highlighting the Importance of Early Recognition and Surgical Debridement.

Fungal infections are a recognized complication of immunosuppression in solid organ transplant recipients. Phaeohyphomycoses are fungal infections caused by a diverse group of dematiaceous fungi. Methods: We share the learning points from 2 Australian cases of phaeohyphomycosis secondary to Phaeacreomonium species (spp). A literature review was performed using Medline, Embase, and Google Scholar to identify this condition among kidney transplant recipients. Results: With the 2 cases reported in this article, a total of 17 cases were identified in the literature. Phaeacremonium spp is ubiquitous in humid and temperate flora, including Australia. Minor trauma is likely the source of inoculation in most cases and diagnosis is often delayed. Presently, no guidelines for management exist given the rarity of this condition. Most known cases have been treated with surgical debulking combined with long-course antifungal therapy. Conclusion: This paper describes 2 Australian cases of phaeohyphomycosis in kidney transplant recipients. A high index of suspicion, especially in the immunosuppressed, is essential for timely diagnosis in kidney transplant recipients. There are several diagnostic and therapeutic challenges that remain with this condition.

Outcomes of live renal donors with a history of nephrolithiasis; A systematic review.

The clinical outcomes of kidney donors with a prior history of nephrolithiasis are poorly defined. We conducted a systematic review assessing the post-donation clinical outcomes of kidney donors with a history of nephrolithiasis. Electronic databases (Ovid and Embase) were searched between 1960 and 2021 using key terms and Medical Subject Headings (MeSH) - nephrolithiasis, renal stones, renal transplantation and renal graft. Articles included conference proceedings and journal articles and were not excluded based on patient numbers. Primary outcome was donor stone-related event. Secondary outcomes were renal function upon follow-up or post-operative nephrectomy complications. In summary, 340 articles were identified through database search. We identified 14 studies (16 cohorts) comprising 432 live donors followed up for a median of 26 months post live kidney donation. Six donors donated the stone-free kidney whilst 23 live donors had bilateral stones. Mean stone size was 4.2 ± 1.4 mm (1-16) with average follow up duration of 21.1 months (1-149). Twelve studies provided primary outcome (n = 138 patients) and eight (n = 348) for secondary outcomes. One donor had a stone-related event upon follow up. A total of 195 patients had eGFR <60 upon follow up. However, they were not significantly different when compared to renal function of live donors that didn't have pre-donation nephrolithiasis. Many of the studies couldn't provide long term follow up, coupled with limited data regarding the nature of the pre-donation stone disease. In conclusion, this systematic review shows that we have very limited information upon which to base recommendation regarding pre-donation risk of post-donation complications. Longer term follow up is required and lifelong follow up with live donor registries will aid further understanding.

Kidney Allograft Retrieval in Donations After Cardiac Death Following Type A0 Dissection Extending to Both Renal Origins.

Controlled organ retrieval in donors after cardiac death has been increasing in Australia to help bridge the gap in demand and supply. Donation of organs from donors with acute aortic syndrome has been scarcely reported. Several concerns exist related to ischemic insults before retrieval from malperfusion, systemic inflammatory state in dissection, and involvement of donor organ vessels that may preclude the ability of surgeons to perform successful anastomosis of healthy vessels. Here, we have described a case in which both kidneys were successfully retrieved from a donor after cardiac death who had a type A0 aortic dissection. Despite radiological malperfusion and concern about vessel integrity, donor organs were unaffected and had immediate graft function.

Transplant Outcomes From Deceased Donors Dying With Burns Injury, a Systematic Review.

AIM: The ever-expanding organ supply and demand gap necessitates alternate sources of organ donors. Initially thought to be a contraindication, organ procurement from nonsurvivable burns patients is possibly an additional organ donor source. We aimed to conduct a systematic review investigating the prevalence and outcomes of the use of burn victims as a source of organ donation for transplantation. METHODS: Medline and EMBASE were searched between 1990 and 2020, using the following keywords: organ procurement, organ donation, organ transplantation, and burns. Studies were not excluded based on patient numbers and included both published abstracts/conference proceeding and journal articles. Studies were excluded if specific organs were not identified or if posttransplant outcomes were not recorded. Primary and secondary outcomes of interest were post-transplantation organ function and complications respectively. RESULTS: Six manuscripts met study inclusion criteria. Fourteen burns donors were identified, including both donation after circulatory death and donation after brain death pathways. The total body surface area of burn ranged from 4% to 90%. A total of 4 hearts, 2 lungs, 8 livers, 1 pancreas, and 24 kidneys were transplanted with varying duration of follow-up and outcomes. CONCLUSION: A very small number of studies have reported the posttransplant outcomes of organs derived from victims of burn injury, including very limited information regarding graft function in the short or long term. Hence, recommendations for the utilization of organs from victims of burn injury should remain guarded and subject to surveillance.

A First Case Report of Cytomegalovirus Infection Presenting With Perianal Fistula and Abscess Formation in a Kidney Transplant Recipient.

Cytomegalovirus infection after transplant has been dramatically reduced in the modern era with improved understanding of immunosuppression and perioperative transplant care. However, cytomegalovirus syndrome with or without tissue invasive disease can still lead to significant morbidity and mortality. Several organs can be involved: most commonly, the gastrointestinal tract, liver, pancreas, lung, and the transplanted renal allograft. Postoperative cytomegalovirus colitis after renal transplant is well recognized and described, with symptoms including abdominal pain, nausea, and diarrhea. Biochemistry can demonstrate pancytopenia with a leukopenia with or without histopathology confirmation. A high index of suspicion is required for a timely diagnosis. This is the first published case report of a patient with cytomegalovirus tissue invasion presenting with a perianal fistula and abscess formation.The diagnosis and management ofthis case with a literature review is discussed.

Utilizing the same incision for staged renal transplant in patients with polycystic kidney disease requiring hand-assisted laparoscopic nephrectomy.

BACKGROUNDS: Many autosomal dominant polycystic kidney disease (ADPKD) patients undergo nephrectomy and subsequent renal transplantation. We report our outcomes after hand-assisted laparoscopic nephrectomy (HALN) where a Rutherford-Morrison incision is used as a hand-port site and kidney extraction site, as well the future incision site for staged transplantation. METHODS: A retrospective review was performed on all adult nephrectomies for ADPKD by the Transplant Surgery department at Westmead Hospital between June 2011 and June 2021. Outcomes were compared between HALN, laparoscopic nephrectomy (LN) and open nephrectomy (ON) including operation time, hospital length of stay (LOS), post-operative complications, subsequent transplantation and post-transplantation wound complications. RESULTS: Twenty-two HALN, 8 LN and 5 ON were performed during the study period. Median kidney weights for HALN, LN and ON were significantly different (1575, 403, 3420 g respectively, P = 0.001). There was a significant difference in LOS between the HALN and ON (5.8 versus 9.8 days, P = 0.04), but not between HALN and LN (5.8 versus 5.1, P = 0.06). There was no significant difference for operation time (P = 0.34) and major complication rates (P = 0.58). There were 8 HALN, 5 LN and 2 ON who have had subsequent renal transplantation with one wound complication, an incisional hernia in the HALN group. CONCLUSION: Our HALN is associated with a shorter LOS and similar complication rate to ON and can be efficiently performed for significantly larger kidneys than LN without a significant difference in operation time or LOS. The same Rutherford-Morrison incision site can be used for transplantation.

Staged versus concurrent native nephrectomy and renal transplantation in patients with autosomal dominant polycystic kidney disease: A systematic review.

BACKGROUND: Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD) frequently undergo native nephrectomy before transplantation. The nephrectomy may be a staged procedure or undertaken simultaneously with transplantation. When performed simultaneously, the transplant procedure is more prolonged, involves a larger operative field and incision. There is also a concern of a greater risk of graft loss with simultaneous nephrectomy and transplantation. Moreover, staged surgery may allow nephrectomy to be performed before immunosuppression introduction via a smaller incision or involving a minimally invasive approach. However, staged nephrectomy may require a period of dialysis not otherwise necessary if a transplant and nephrectomy were simultaneous. Moreover, only a single procedure is needed, implying the avoidance of a prior nephrectomy and its attendant morbidity in a patient with chronic renal insufficiency. To account for these issues, this study aims to compare the cumulative morbidity of two-staged procedures versus a single simultaneous approach in term of morbidity and graft outcomes. OBJECTIVES: This study aims to systematically review the literature to determine whether a staged or simultaneous approach to native nephrectomy in ADPKD is the optimal approach in terms of morbidity and graft outcomes. METHODS: A literature search of MEDLINE and EMBASE was conducted to identify published systematic reviews, randomized control trials, case-controlled studies and case studies. Data comparing outcomes of staged and simultaneous nephrectomy for patients undergoing kidney transplantation was extracted and analyzed. The main outcomes analyzed were length of hospitalization, blood loss, operative time, other early postoperative complications and risk of graft thrombosis. Meta-analysis was conducted where appropriate. RESULTS: Seven retrospective cohort studies were included in the review. There was a total of 385 patients included in the analysis, of whom 273 patients underwent simultaneous native nephrectomy and kidney transplantation. Meta-analysis showed an increased cumulative operative time in staged procedures (RR 1.86；95% CI 0.43-3.29 p = 0.01) and increased risk of blood transfusions (RR 2.69; 95% CI 1.92-3.46 p < 0.00001). For the transplant procedure, there were no significant difference in the length of stay (RR 1.03; 95% CI -2.01-4.14 p = 0.52), major postoperative complications (RR 0.02; 95% CI -0.15-0.10 p = 0.74) and vascular thromboses (RR 1.42 95% CI 0.23-8.59 p = 0.7). CONCLUSION: The results suggest that staged nephrectomy followed by kidney transplantation is associated with a longer cumulative operative time and increased cumulative risk of blood transfusions. There is no evidence to suggest that performing a simultaneous nephrectomy and kidney transplant procedure increases the perioperative mortality rate, major postoperative complication rates or risk of vascular thrombosis.

Renal allograft compartment syndrome: a review.

Renal allograft compartment syndrome (RACS) is the result of extrinsic compression resulting in graft dysfunction and loss due to ischaemia. A literature review was performed by computerized searches from the following data sources Medline, EMBASE, PubMed and Cochrane Library databases. Risk factors include size mismatch between graft and recipient. Intraoperative suspicion should be exercised if there is poor tissue turgor, cyanosis and loss of urine output upon fascial closure. Doppler ultrasound is the modality of choice amongst the literature to aid in diagnosis of RACS. From our study, the accepted form of treatment is early detection and appropriate surgical intervention. Nevertheless, it is clear from the paucity of literature that further investigation into this area of transplantation is necessary.

How to repair a donor renal vein injury with an inferior vena cava patch.

Shortage of supply of organs for donation means that every viable organ should be given the best chance possible for transplantation. As such, we present a method of renal vein reconstruction of a deceased donor kidney following injury during the organ recovery process.

Comparison of the effect of single vs dual antiplatelet agents on post-operative haemorrhage after renal transplantation: A systematic review and meta-analysis.

OBJECTIVES: A significant proportion of renal transplant patients have cardiovascular comorbidities for which they receive treatment with antiplatelet agents. The aim of this study was to systematically review the current literature reporting perioperative outcomes for patients receiving dual antiplatelet therapy compared to single antiplatelet therapy at the time of kidney transplantation with particular reference to the risks of postoperative haemorrhage. MATERIALS AND METHODS: Embase, Medline and Cochrane databases were utilized to identify articles reporting outcomes of renal transplant recipients on single antiplatelet therapy and dual antiplatelet therapy. These outcomes were compared using a random effects model meta-analysis where appropriate. RESULTS: Six articles were incorporated in the analysis, including 130 receiving dual antiplatelet therapy, and 781 in the single antiplatelet therapy group. There was a significantly higher risk of post-operative haemorrhagic events in the dual antiplatelet therapy group compared to the single antiplatelet therapy group (RR 1.58, 95% CI 1.19-2.09, p = 0.001). Post-operative cardiovascular event rates were similar between both groups in individual studies, although this could not be quantitatively analysed. CONCLUSIONS: The use of dual antiplatelet therapy was associated with a higher risk of post-operative haemorrhage compared to the use of single antiplatelet therapy without increased rates of surgical intervention. However, the use of dual antiplatelet therapy may provide protection from cardiovascular events in an inherently higher risk patient group.

Prophylactic Wound Drainage in Renal Transplant: A Survey of Practice Patterns in Australia and New Zealand.

OBJECTIVES: Drains are used routinely in many centers at the conclusion of kidney transplant, despite a paucity of evidence to guide practice in kidney transplant. Studies have not shown benefit from prophylactic drain placement following other major abdominal and vascular operations, and usage is consequently declining. Our aim was to understand practice patterns and rationale for behavior in drain placement and management in kidney transplant. MATERIALS AND METHODS: We conducted an online survey of surgeons who routinely perform kidney transplants across Australia and New Zealand. RESULTS: The response rate was 66% (43/66). Of respondents, 61% reported routine drain insertion, whereas 21% seldom inserted drains. Concerns about bleeding and anticoagulation (63%) and routine practice (58%) were the dominant reasons for drain insertion. The factors selected as most significant in determining drain removal were both volume and time (44%) and volume alone (33%). A volume of < 50 mL/day (51%) was the most commonly reported threshold for removal. The postoperative period of days 3 to 5 was the most commonly selected time point for drain removal (63%). Seventy-four percent of respondents would consider enrolling their patients in a randomized controlled trial to determine the benefits and harms of drain insertion. CONCLUSIONS: Although drain insertion is a common practice, transplant surgeons in Australia and New Zealand reported sufficient uncertainty concerning the potential benefits and harms to warrant design and conduct of a randomized controlled trial.

Beware the band adhesion: an unexpected cause of double obstruction following intraperitoneal kidney transplantation.

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.

Renal Transplant Artery Autologous Saphenous Vein Graft Aneurysms: Late Presentation and the Need for Recall and Surveillance.

Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particularly in living donors with short donor vessels or after donor vessel injury during allograft procurement. Autologous saphenous vein graft aneurysm formation is described as a late complication following the use of this conduit in renal transplant. We report a case of a 45-year-old woman who developed an autologous saphenous vein graft aneurysm 21 years after her living donor transplant, which was successfully managed with explantation of the graft, cold perfusion ex situ, and resection of the aneurysm, which was followed by reconstruction using deceased donor iliac vessels. The graft was then successfully reimplanted. Based on this experience and after a review of the literature related to autologous saphenous vein graft aneurysms in renal transplant, we recommend that surveillance for this particular complication should be considered no later than 10 years after implant of an autologous saphenous vein graft when used as an arterial conduit.

Endovascular Management of Mycotic Pseudoaneurysm After Pancreas Transplantation: Case Report and Literature Review.

INTRODUCTION: Mycotic pseudoaneurysm is a rare complication of pancreas transplantation. Successful management relies on early diagnosis and expedient treatment comprising surgery and antibiotics. While the standard of care in recipients of pancreatic transplants is open repair of pseudoaneurysm with or without excision of the allograft, endovascular management has been reported. Endovascular repair is a less invasive treatment option with advantages of expedient control of hemorrhage, avoidance of adhesions with an open repair, and greater suitability for elderly and frail patients. MATERIAL AND METHODS: We report a case of a 40-year-old recipient of a pancreas transplant who had a mycotic pseudoaneurysm managed with endovascular repair. A systematic search of PubMed-MEDLINE, Embase, and Cochrane Library was performed of all cases of mycotic aneurysms following pancreas or kidney transplantation managed with endovascular repair. RESULTS: There were 14 cases of mycotic aneurysms in transplant recipients managed with endovascular repair in the literature. Of those who received an endovascular stent as the only initial management strategy, 6 (54.5%) required a subsequent graft excision. Four (28.6%) patients required excision of their stent due to continued sepsis. There was 1 death from unrelated causes. CONCLUSIONS: Endovascular repair was a reasonable bridging technique to further definitive surgical treatment in our case. Endovascular management may be used with caution in high-risk patients. We advocate for prolonged antibiotic therapy combined with vigilant surveillance of the clinical response, and a low threshold for allograft excision in the event of clinical deterioration.

How to do it: a robotic kidney autotransplant.

We describe Australia's first reported case of robotic kidney autotransplantation for a complex renal artery aneurysm. It is potentially a safe, minimally invasive method of salvaging renal parenchyma and preservation of renal function in patients with complex renovascular conditions. This technique shows promise in carefully selected patients performed in centres with surgeons experienced in both kidney transplantation and the robotic platform.